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Abdominal Pain DESCHUTES COUNTY ADULT JAIL SO-501 L. Shane Nelson, Sheriff Standing Order Facility Provider: December 6, 2017 STANDING ORDER ABDOMINAL PAIN 1. Assessment a. History i. Location, duration, pattern of pain (constant or intermittent) ii. When did it start and anything precipitating/leading up to the start of the pain? iii. Anything tried to make the pain better? Did it work? Anything that makes the pain worse (does passing stool/flatus improve the pain?) iv. History of abdominal surgeries? v. LMP for female inmates, chance she is pregnant? vi. Last BM vii. Associated symptoms: nausea, vomiting, diarrhea, constipation, loss of appetite, fever, vaginal bleeding, vaginal discharge, penile discharge, testicular pain, hematuria, dysuria, black tarry stools, bloody stools, coffee-ground emesis. b. Exam (exam is best done without asking the inmate if he/she has pain in various areas, if there is pain it will be evident upon exam. This is an objective exam, so n) i. Ask inmate to move to exam table, observe movements from chair to a laying down position – someone in pain will have difficulty doing this and it will be evident, especially with using abdominal muscles to get to a laying down position. Also, observe inmate when gets up from the exam table. Any visible signs of pain with these movements and ambulation? ii. Auscultate bowel sounds prior to any palpation iii. Observe abdomen, is it distended, flat, obese? iv. Palpate all areas of the abdomen separately with knees bent – epigastric, LUQ, RUQ, LLQ, RLQ, umbilical, suprapubic – where is pain the worst? Is it generalized in all quadrants? v. Is there involuntary guarding? (Put hands on both sides of lower abdomen and alternate pressing quickly between both hands. If there is involuntary guarding the abdomen will be tense and you will be unable to press down.) Supersedes: February 10, 2016 Review Date: December 2019 Total Pages: 3 1 DCAJ 10.040 February 10, 2016 vi. Specific signs and pain at specific sites – McBurney’s point, Psoas sign, Murphy’s point vii. Obtain urine HCG for all female inmates regardless of reported LMP viii. Document all your findings 2. Management a. Contact the Facility Provider or send to the Emergency Room if you are concerned for any of the following medical emergencies: Condition History (reported from patient) Exam (objective evidence) Appendicitis Acute onset of constant pain Pain is worse in RLQ, positive worsening over the past 24-48 Psoas sign, pain at McBurney’s hours localized to the RLQ, loss of point with deep palpation, appetite and nausea will be involuntary guarding, present, fever and vomiting may be ambulating/movement will present. cause pain, rebound tenderness may be present Ovarian Acute onset of constant moderate Pain is unilateral to affected Torsion to severe pelvic pain that coincides side that can radiate into the with intermittent waves of nausea pelvis, tachycardia and low and sometimes vomiting grade fever may be present, you may or may not palpate a mass in the affected side Ectopic Acute onset of sudden lower Urine HCG will be positive, Pregnancy abdominal pain (may be diffuse or abdominal tenderness in localized to one side) with vaginal lower quadrants, may have spotting or bleeding, may be “late” rebound tenderness on period and bleeding will start with abdominal pain which inmate may think is normal period, may have nausea and vomiting. Usually presents 6-8 weeks after missed period. Bowel Periumbilical pain with intermittent Tachycardia, may have Obstruction cramping pain every 4-5 minutes, hypotension and fever, inability to pass flatus and stool, abdomen will be distended may have nausea and vomiting, with diffuse tenderness, emesis may be bile-stained, history hyperactive high-pitched of abdominal surgeries or cancer bowel sounds when early obstruction, hypoactive the longer it progresses, involuntary guarding present Acute Acute onset of prolonged constant Fever, ill-appearing, Cholecystitis (>4-6 hours), severe, RUQ or tachycardia and movement epigastric pain that may radiate to will be very difficult, the right shoulder or back, fever, involuntary and voluntary nausea, vomiting, and loss of guarding of abdomen, positive DCAJ 10.040 October 3, 2002 appetite usually present Murphy’s sign, severe cases may have signs of bowel obstruction Perforated Abrupt onset of severe pain, within Initially pain is epigastric but Gastric Ulcer 30 minutes pain is diffuse and then quickly (within 30 mins worsening, no appetite, possible of onset) becomes diffuse and hematemesis, may have no known abdomen becomes rigid history of ulcerative disease or (board-like abdomen) symptoms of this b. If no concern for medical emergency, please schedule inmate to be seen by provider at next clinic day to evaluate and manage abdominal pain. c. Contact the Facility Provider if you would like any medications given for associated symptoms with abdominal pain if you feel inmate needs medications before Provider is able to assess. 3 .
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